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Info For Medical Providers

Information For Medical Providers

Below is a list of questions regarding ordering diagnostic tests and referrals for other treatment.


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Questions regarding ordering diagnostic tests, and referrals for other treatment

1) Ordering diagnostics and referral for other treatment

If you are having trouble getting the insurer to authorize a diagnostic imaging study, WCD has a rule that can force the insurer to act: OAR 436-010-0230 (12) (Effective Oct. 1, 2015) indicates that a medical provider may contact an insurer in writing for pre-authorization of diagnostic imaging studies other than plain film X-rays. The insurer is required to respond to the provider's request in writing whether the service is pre-authorized or not pre-authorized within 14 days of receipt of the request.

For other services, such as physical therapy or EMG studies, the WCD has indicated that the insurer cannot ignore requests for preauthorization as it can stall the worker’s ability to access the care needed to get better. If providers want preauthorization for services, we recommend requesting that in writing so a record can be tracked if a medical dispute must be made to force the insurer to make a decision.

A Requests for Surgery must be in writing, and the WCD mandates that the insurer has 7 days to respond.

2) Treatments that can be provided under a closed claim

While curative medical care is only available under an open claim, you can provide a certain kind of medical treatment to injured workers with a closed claim. The following are some examples of medical treatment available to an injured worker with a closed claim:

  • You may prescribe ongoing prescription medication for a patient with a closed claim.
  • Order diagnostic services. Diagnostic treatment can be especially helpful under a closed claim if your patient has ongoing complaints and you suspect they may be suffering from a newly developed condition, a condition that has not yet been identified, or when there has been a worsening of an existing condition (for more information, see the section on aggravation and new/omitted condition claims below).
  • Palliative care to temporarily restrict or reduce the intensity of an otherwise stable condition. Palliative care is available to injured workers who are working or engaged in vocational retraining where treatment is necessary to enable the worker to continue in current employment or vocational retraining. You must submit a written request for palliative care to the insurer. In it, you must identify the condition for which palliative care is being requested, as well as objective findings. In the written request you must also include a treatment plan with the names of the provider who will provide the care, and specify the treatment modalities and the frequency and duration, not to exceed 180 days, and explain how the services will help your patient to continue employment or vocational retraining. The insurer has 30 days to approve a palliative care plan.
  • Curative care that is generally only available for open claims is available under a closed claim in order to stabilize a temporary and acute waxing and waning of symptoms.
  • Curative care for an aggravation of an injury where the compensable work injury has worsened and may require comprehensive medical treatment or even surgery for your patient to get back to medically stationary status (see section below on aggravation claims).

Importance Of Providing Work Restrictions

Injured workers may be entitled to time loss (wage replacement) benefits if they are completely unable to work. They may also be entitled to time loss benefits if they are capable of modified work but their employer does not have modified work available. However, an injured worker is only entitled to time loss benefits if a doctor takes him or her off work or provides work restrictions in writing. You must specify if the injured worker is to remain off work or has with work restrictions after every visit. You may also specify an open ended work restrictions by indicating in writing that your patient is off of work until further notice. Additionally, retroactive work restrictions can be authorized for up to 14 days.

If an injured worker's claim has been denied, it is important to continue to provide work restrictions or provide an open ended work restriction if applicable. That way, if the injured worker prevails over the denial, they will be able to recoup time loss benefits owed while their claim was in denied status. It is also important to continue to provide work restrictions when applicable even if the injured worker has been terminated from employment and is not working.

Getting Paid For Medical Services

If you are not paid for medical services provided to an injured worker because the claim is denied, the insurer is required to pay your bills if the denial is overturned or if the injured worker enters into a Disputed Claim Settlement (DCS) with the insurer. It is important that you continue to bill the insurer even where a claim has been denied because if an injured worker wins at a hearing, the insurer must pay all of the medical bills in its possession after a judge’s order is final. If an injured worker enters into a Disputed Claim Settlement (DCS), any medical bills in the insurer’s possession must be paid out of that settlement.

If you are treating an injured worker with an accepted claim but your medical bills are not getting paid, you may need to initiate a medical services dispute with the Workers’ Compensation Division. You can initiate a dispute with Form 2842 available on the Oregon Workers’ Compensation Division website.

If you are aware that your patient has an attorney, you should reach out to the attorney directly for assistance with any unpaid or denied medical bills. For attorneys that represent injured workers it is a priority that our clients get the treatment they are entitled to and that their medical providers get paid for services.

Q: When should the provider make an aggravation claim?

A: Providers generally make aggravation claims before getting the diagnostic services they need to substantiate whether a pathological worsening has occurred. You can order these diagnostic services under a closed claim without first filing an aggravation claim. Doing so prevents unnecessary litigation and excess claims processing for claims that were made prematurely.

Q: When should the provider tell the worker to ask for a new condition to be accepted?

A: If you suspect that the worker suffered more than the simple strain or contusion condition accepted, you should order the diagnostic tests you need to confirm your diagnosis before suggesting that the worker add this condition to the claim.

The best way to frame your request for diagnostics for a condition that is not accepted under the claim is to just say you "need these diagnostic services to determine the nature and extent of the work injury."

Workers' Compensation

How do I find a good doctor?

You should see if your primary care doctor will help you. However, many primary care doctors no longer deal with Workers’ Compensation. If that’s the case, look for a reputable doctor. Check reviews, ask other injured workers who their doctor was or check with a workers’ compensation attorney. Finding a good attending physician is the single most important thing you can do to get the care you need and benefits you are entitled to for your injury.

Do I have to follow up with the doctor that I am directed to at an urgent care clinic or the emergency room?

If you initially present for treatment at an urgent care clinic or the emergency room, you will often be directed to a follow up appointment. You are not obligated to follow up with that doctor but rather can choose to find another doctor of your choosing. Because your attending physician is so important to your claim, it is important to find a doctor you trust that is supportive of your claim.

Can my employer tell me where to get medical treatment?

No, it is against the law for your employer to direct your medical care. Instead, you are free to seek medical care with a provider of your choosing. If you don’t know where to go, your primary care doctor is often times a good place to start. If the employer has directed your care, alert the ombudsman for injured workers at 503-378-3351.

I’m doing modified work for my employer but what do I do when they give me work beyond my restrictions?

Unfortunately, this is a common problem. The best way to handle this is to have a copy of your doctor’s work restrictions with you at work. If you are asked to do work that is outside of your restrictions, politely point out that what you are being asked to do is outside your doctor’s restrictions. Make clear that you want to do modified work, but that you cannot physically do what is being asked of you. Talk with your attending physician about any problems you are having to see if the doctor can clarify or further restrict the work you are being released to. It is very important that your doctor and employer do not think you just don’t want to work. If the doctor thinks you are trying to shirk work, it creates real problems with your claim.

What if I get injured on the job but I’m not sure I want to file a workers’ compensation claim?

You should document an injury sustained on the job in writing and notify a supervisor immediately, even if you do not plan to file a workers’ compensation claim. While initially a tweak or a strain sustained on the job may not seem like a big deal, you protect your right to file a workers’ compensation claim in the future.


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Info For Medical Providers

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    and got a concussion, I was surprised by how many serious symptoms I was having. I had not known what a “mere” concussion can really do to someone. Then, to add insult to injury, my workers compensation claim did not go smoothly. Luckily, though, I called Swanson, Thomas, Coon & Newton, and spoke with Stephanie Bales, Christine Frost’s assistant. She was like a ray of sunshine for me: someone who listened to me, took me seriously, and made me feel as if there was someone out there ? besides my doctor ? who was on my side. That meant a lot to me.
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  • My name is John Gray
    and as a former and extremely satisfied client of Swanson Thomas Coon and Newton I would like to briefly convey my experience. The firm has represented me from the onset of my Work place accident, through the hurdles of the Oregon Worker’s Compensation system, Third Party Liability, all the way to Social Security Disability. The specialized representation I received has made my life better in too many ways to share. My education by my attorneys on all the pitfalls of each claim type and area, meant knowledgeable communication by myself and my attorneys, resulting in a positive resolution on all counts.
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